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Introduction
Housing is a key determinant of health. Substandard housing quality remains a public health issue in the United States. According to the United States Dept. of Housing and Urban Development's (HUD) 2007 American Housing Survey, 6 million households live with moderate or severe physical housing problems. As many as 24 million households have lead-based paint hazards. Maintenance and upkeep of public and low-income housing remains a major issue, leading to chronic problems of water infiltration, pest infestation and unsafe physical conditions. The disproportionate burden of these problems falls to children, the elderly and those with chronic illnesses. Furthermore, there is an especially high burden on minorities.

The categories of deficiency in housing, as defined by the U.S. Census Bureau, are plumbing, heating, hallways, upkeep, electric service and kitchen equipment. Substandard housing is associated with a number of negative health outcomes including, respiratory infections, heavy metal poisoning (e.g. lead), asthma and injuries. There may also be a toll on mental health, and an association with obesity and its related morbidities.

History
Even though housing quality is better today than what it was at the beginning of the 20th century, close to 6 million Americans live in severe or moderate housing conditions. The majority of those living in these extreme housing conditions are minorities and renters. Today’s poor housing and neighborhood conditions are a symptom of historic inner city disinvestment and population loss influenced by ill conceived federal housing policy and finance.

For example, after World War 2, the FHA played a major part in influencing those with the means to leave the inner city for the suburbs. According to Schwartz, the FHA gave preferential treatment to insuring mortgages in the suburbs rather than the inner city. In fact, the FHA considered black neighborhoods too risky of an investment to insure mortgages. The result was many middle-class families left the inner city, taking with them jobs and opportunity. This left poor black families in neighborhoods that were quickly beginning to be characterized by vacant lots, abandoned buildings, crime, and economic insecurity.

Today, the recent recession, foreclosure crisis, and the decline of the U.S. auto industry has further exacerbated many of the problems inner city neighborhoods face. People are moving out of their neighborhoods as banks foreclose their homes leaving blocks of vacant homes and lots. Those left in declining neighborhoods are more likely to experience the negative health outcomes associated with poor housing and neighborhood conditions.

Definitions
The World Health Organization (WHO) provides a useful framework for thinking about housing conditions. According to the WHO, housing should provide:
 * protection against communicable diseases,
 * protection against injury, poisoning, and chronic diseases,
 * and reduce psychological and social stresses to a minimum.

Housing that does not meet the above conditions could be considered as substandard or poor. Homes that are lacking toilets, have faulty or unreliable heating systems, or have exposed electrical wiring do not protect inhabitants from disease and injury and can cause serious psychological stress. Schwartz characterizes these extreme conditions as being "severe" housing problems.

"Severe" housing problems are not very common in the United States. American are more likely to experience "Moderate" housing problems. These can be thought of as having unvented gas, oil, or kerosene as the primary heating source, or lacking a kitchen sink. Again, the lack of commonplace appliances like a furnace or sink can expose inhabitants to diseases and injury.

It is also important to note that housing quality can be an indicator of neighborhood conditions. Typically, neighborhoods that are seen as bad or deteriorating are often characterized by the conditions of the housing in that neighborhood. Poor neighborhood conditions can be defined as having abandoned buildings, vacant lots, no access to quality schools, and high levels of poverty. These neighborhood dynamics can contribute to a person's psychological and social stress.

Bashir puts all of the above into context when the social and physical characteristics of low-income neighborhoods are brought into the picture. Crime and noxious noise and odors force individuals to isolate in substandard homes, which often characterize low-income neighborhoods. The combination of avoiding outside activity and isolating in dangerous living spaces leads to negative health outcomes such as obesity, lead poisoning, and asthma.

Statistics
Poor housing conditions can also be characterized by race and geography. Of the 6 million Americans who experience poor housing conditions, Blacks and Hispanics fare much worse than Whites. Moreover, poor housing conditions are disproportionately found in inner cities and rural areas as opposed to the suburbs. Given these realities, it becomes easy to understand why inner city minorities have poorer health than suburban Whites.

Black homeowners are more likely than Hispanic and White homeowners to experience severe and moderate housing conditions. Of homeowners with moderate housing quality problems, 5.9% were black and 3.8% were Hispanic. Of the homeowners with severe housing quality problems, 1.2% were black and 1.1% were Hispanic.

The same is true for Black renters. They are more likely than Hispanics and Whites to experience severe and moderate housing conditions. Of the renters with moderate housing quality problems, 7.9% were black and 7.1% were Hispanic. Of the renters with severe housing problems, 4.2% were black and 3.4% were Hispanic.

Homeowners in central cities and rural areas are more likely than homeowners in the suburbs to experience "severe" and "moderate" housing problems. Of the homeowners with severe housing problems, 1.2% were in central cities while .8% were located in suburbs and 1.1% were located in rural areas (Schwartz, 2010). Of the renters with severe housing problems, 3.7% were located in central cities while 2.6% were located in suburbs and 2.7% were located in rural areas.

Renters in central cities and rural areas are more likely than renters in the suburbs to experience "severe" and "moderate" housing problems. Of the homeowners with moderate housing problems, 2.7% were located in central cities while 1.4% were located in suburbs and 2.8% were located in rural areas (Schwartz, 2010). Of the renters with moderate housing problems 7.6% were in central cities while about 5.6% were located in suburbs and about 7.8% were located in rural areas.

Specific Health Outcomes
Asthma and respiratory illnesses

Asthma is a major cause for childhood hospitalizations as well as absenteeism from schools. Asthmatic children living in homes with cockroaches, mice and mold may be especially prone to episodes requiring medical care. Direct health care costs of asthma totaled more than $14.7 billion in 2008. $5 billion annually in indirect costs, primarily from lost productivity, can be added to the total. According to the Centers for Disease Control and Prevention , almost 13 million lost school days, 4 million asthma attacks and nearly 4,000 deaths yearly are associated with asthma. Water infiltration and poor ventilation increases the likelihood that moisture will be an issue in a home, which can lead to infestation of pests and to mold growth, known triggers of allergies and asthma.

Lead

High lead levels (blood levels ≥10 micrograms per deciliter) are associated with a number of poor health outcomes, including: learning disabilities, behavioral and neurological problems, and, in severe cases, death. Even relatively low blood lead levels can have negative health impacts. The impact on the individual and on society in terms of lost potential can be dramatic. Those living in older, poorly maintained housing are at the greatest risk, and many of these housing units are home to low-income families Even though blood levels are dropping in much of the population in the United States, the poorest children remain at the greatest risk because they are most likely to live in older, poorly maintained housing.

Unintentional injuries

Unintentional injury is the leading cause of death among children under the age of 15. Deaths from residential injuries accounted for an average of 2,822 deaths annually from 1985-1997. The rates of death associated with residential injury are equally significant amongst those aged 65 and older. Poorly maintained stairs, sidewalks, bad lighting, and inadequate facilities for people with limited mobility or sensory impairments are all implicated in injury rates.

Chronic illness

Even after accounting for other potential contributors like income, smoking or employment status, poor housing conditions are associated with an increased risk of chronic respiratory infection. Unsanitary conditions made more severe by aging and poorly constructed structures, exacerbate the problem. Poor heating and cooling lead to an increased risk of temperature related illnesses. Heat stroke and exhaustion are a major cause of mortality and morbidity, especially for the elderly. Conversely, exposure to cold temperatures can contribute to an increased use of health services

Nutrition and obesity

There has been much focus the past few years on what have been coined “food deserts”, that is the lack of grocery stores or markets that contain healthful foods like fruits and vegetables. These “deserts” are primarily in high poverty, inner-city areas where residents lack the resources to travel. These areas are also often rife with stores selling convenience foods and liquor. Rates of obesity and the related illnesses are much higher in these areas than in higher income communities with easy access to fresh foods. A correlation has been determined for a connection between food insecurity associated with housing cost burdens and under-nutrition. A lack of adequate play areas for children, poor lighting or sidewalk condition can also lead to a lack of physical activity which is associated with increased obesity and associated morbidities, such as type II diabetes, cancer and cardiovascular disease.

Intentional injuries

Neighborhoods of low socioeconomic status are associated with higher rates of intentional injuries (violent crime). Poor investment in community property, and the lack of private and semi-private space can lead to the inability of residents to properly or adequately maintain defensible space. A lack of “eyes of the street” due to poor design or poor maintenance only makes crime prevention more difficult.

Physical Deficiencies
There are a number of housing-quality issues that can directly or indirectly affect health outcomes, some of which are not addressed by the U.S. Census Bureau, or HUD.


 * Ventilation: Inadequate ventilation, either through natural or mechanical means, can allow for excess moisture in the house which can lead to mold growth or pests.  Mold and by-products of pest infestations can exacerbate symptoms of allergies and asthma for sensitive individuals.


 * Heating & cooling: Inadequate temperature control is directly related to heat injuries.  The elderly and the young are especially sensitive to over-heating.  Each summer, people living in housing with no or poor cooling facilities are hospitalized or die.  Conversely, extreme cold temperatures can contribute to an increased use of medical services.


 * Water infiltration: A major contributor to pest infiltration.  Cockroaches, rats and mice require a stable source of water, and without it, they will not inhabit a building.


 * Lead and chemical hazards: Lead has remained a constant contaminant in the older housing stock in the United States.  Lead was commonly used in house paints until it was banned in the U.S. in 1977.  Additionally, tetraethyl lead was used as a gasoline additive until the 1990’s. These common uses contributed to the lead that is found in and around houses, and that contribute to lead poisoning.  Lead has received much attention as it is both ubiquitous and recognizably harmful to health.  There are however a number of other known or potential hazardous chemicals used in the construction or maintenance of housing.  Included in these are formaldehyde, flame retardants and plasticizers.


 * Neighborhood context: Where the housing is located is a significant factor in determining health outcomes.  Unsafe neighborhoods, due to crime, traffic, or other infrastructure problems, force residents indoors, discourage neighborhood connections and inhibit outdoor activities.


 * Maintenance: Poorly maintained housing is a significant contributor to many of the other issues, including ventilation, heating and cooling and chemical exposures. It is also related to unintentional injuries; broken sidewalks and stairs, inadequate lighting and plumbing problems are just a few of the common maintenance problems.

Interventions / Policy
Policy makers and housing quality and health advocate should consider several factors when thinking about a potential solution to the problems of housing quality and health.
 * First, solutions should be comprehensive. This means solutions should consider not just the home but also the entire community ). For example, characteristics associated with poor housing quality such as cockroaches, ventilation, or moisture can cause negative health outcomes such as asthma. While Cockroaches are symptom of poor ventilation and moisture, they may also be a consequence of a community level problem like trash left unattended in the street. To this end, solutions that just focus on the home may be missing a larger problem like community norms.


 * Second, it is important to consider the role discrimination plays when it comes to the race and geography of poor housing conditions. Stone and Rosenbaum suggest that discrimination is a possible reason why minorities, Blacks in particular, are more likely to live in poor quality neighborhoods compared to Whites. Blacks may not have access better quality neighborhoods and homes. Strengthening or enforcing Fair Housing laws may be a way to narrow the disparity between not only the housing conditions of Blacks but also the disparities of their health outcomes.


 * Third, careful attention should be paid to the relationship between housing and health trends. Jacobs et al. suggest that the relationships between housing and health trends are both positive and negative. For example, the increased use of air conditioning units may be related to increases in incidence of asthma. There may be a relationship between deteriorating neighborhood conditions and stress related health outcomes. Jacobs et al. hope that policy makers will consider the financial costs of these negative outcomes as they develop plans and designs for housing and neighborhoods.